Basic Information
| Provider Information | |||||||||
| NPI: | 1336458215 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | JEAN E FORSBERG PLLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 268996 | ||||||||
| Address2: | |||||||||
| City: | OKLAHOMA CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 731268996 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4057050018 | ||||||||
| FaxNumber: | 4057050029 | ||||||||
| Practice Location | |||||||||
| Address1: | 1801 W 3RD ST | ||||||||
| Address2: | |||||||||
| City: | ELK CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 736445145 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5802252511 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/27/2010 | ||||||||
| LastUpdateDate: | 03/18/2011 | ||||||||
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| AuthorizedOfficialLastName: | CHEADLE | ||||||||
| AuthorizedOfficialFirstName: | ROSIE | ||||||||
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| AuthorizedOfficialTitleorPosition: | BILLING SUPERVISOR | ||||||||
| AuthorizedOfficialTelephone: | 4057052644 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 291U00000X | 37D0472420 | OK | Y | Laboratories | Clinical Medical Laboratory |
ID Information
| ID | Type | State | Issuer | Description | 200317000A | 05 | OK | MEDICAID |